Is this your first time attending a CT Community College? Yes   No

Name:

Email Address:

Street Address:

City: State: Zip:

Birthdate:  Day Number:

Social Security Number: Gender: Male Female

U.S. Citizen: Yes   No

  I am enrolling in a CE course and would like to be entered into a sweepstakes to win a free online Ed-2-go ® class. (A $99 value)

Ethnicity: Hispanic/Latino Non-Hispanic/Non-Latino Decline to State

Race: White  Black or African-American American Indian or Alaskan Indian
     
Asian   Native Hawaiian or Other Pacific Islander Other Decline to State

Course Name & CRN Number:   

Method of Payment: Check    Visa    MasterCard      

Amount:   Credit Card #:   Exp.Date: 3-Digit Security Code:

Zip Code of Credit Card Holder:
(Required by Credit Card Company)

I acknowledge and authorize that photocopies and fascimiles of the original of this consent of the Disclosure of Education Records, including my signature, shall be as valid as the original. I also pledge myself to comply, in good faith with all the rules and regulations of the College. I realize that any misleading information on this application may be cause for dismissal.

Signature: Date:
Signature Only - Do Not Key

Payment must accompany your registration.

Please make your check or money order payable to:
Three Rivers Community College

Mail your completed registration form to:
Three Rivers Community College
Continuing Education Department
574 New London Turnpike
Norwich, CT 06360-6598
(860) 885-2608
or
Fax your completed registration with credit card information to:
(860) 886-5063

Please read our refund policy below.

NONCREDIT REFUND POLICY